“Doc, Should I See You or My Oncologist?” A Primary Care Perspective on Opportunities and Challenges in Providing Comprehensive Care for Cancer Survivors

Abstract

As a primary care provider, my answer to the question raised in the title of this editorial is simple: a cancer survivor should see a primary care provider. Ask an oncologist or a cancer survivor, and the answers are likely to vary. I have heard my oncology colleagues say that they enjoy “social” visits from their cancer survivors, but at the same time, they are concerned about their full schedules, which do not allow them sufficient time to see newly diagnosed patients. I have heard patients with cancer and their family members question the need to see primary care providers and ask in bewilderment which specialists they should see for their organ-related complaints. Although I have had cancer survivors who have “forgotten” about their prior cancer diagnoses, I have 5-year survivors of early breast cancer who not only see me regularly, but also seek annual visits with their oncologists, radiation oncologists, surgical oncologists, and gynecologists. In light of the growing number of cancer survivors, many of whom are living longer, the article by Cheung et al addressing survivorship care in this issue of Journal of Clinical Oncology (JCO) is relevant and timely. Cheung et al surveyed 255 primary care providers, 123 oncologists, and 431 of their so-called cancer-free patients to compare expectations for cancer survivorship care. The survey asked patients to describe the degree of responsibility that their primary care providers or the oncologists should assume with respect to surveillance of their most recent cancer, screening for cancers other than their primary malignancy, general preventive health, and management of other comorbidities. The physician surveys—sent to the one primary care provider and one oncologist identified by each patient as the main physicians responsible for his or her care—asked physicians to describe their perceived roles in the same four areas. The study included 409 matched patient-oncologist pairs, 233 patient–primary care provider pairs, and 232 primary care provider–oncologist pairs. The study found that although patients expected both their oncologists and primary care providers to be involved in surveillance for cancer recurrence and other cancer screening, they expected the oncologists to be primarily responsible for cancer recurrence. Although most oncologists agreed with having a significant role in surveillance for cancer recurrence, about half expected to play a minimal role in screening for other cancers, and about one third expected to share this responsibility with the primary care providers. Most primary care providers expected to be responsible for both screening for other cancers and cancer recurrence, although about one third expected to share this role with the oncologists. Patients clearly preferred their primary care providers to have a major role in general preventive care and treatment of other comorbidities, and did not expect their oncologists to have a significant role in these aspects of care. For the most part, primary care providers and oncologists agreed with their patients. Oncologists and primary care providers agreed that the latter group should have a significant role in treating other medical problems (in fact, 84% of primary care providers expected to have full responsibility). Although oncologists were interested in sharing responsibility for general preventive care with primary care providers, primary care providers expected to have full or most of the responsibility for this aspect of care. The Cheung et al findings suggest that patients expect their oncologists, primary care providers, or both to be responsible for their care; that oncologists want to have a role in cancer-related care; and, not surprising to me, that my primary care colleagues expect to have a significant role in essentially all domains of cancer survivorship care. So where do we go from here? What is the role of primary care providers in cancer survivorship care? Whether patients have cancer, congestive heart failure, or diabetes, primary care providers are trained to provide comprehensive care to patients with complex medical conditions. Therefore, primary care providers should be best equipped to handle each of the four areas of cancer survivorship care outlined in the Cheung et al study. But are they? Great focus is placed on chronic diseases, such as congestive heart failure, diabetes, and end-stage renal disease, in general medical education and residency training. However, aside from the few exceptions likely to emerge, there are no curricula focusing on cancer survivorship. General medical training in cancer focuses on the acute phase and occurs mostly in inpatient settings (although there is some exposure to ambulatory care). In previous studies, although primary care providers expressed an interest in caring for cancer survivors, only about half reported being comfortable with having responsibility for surveillance of cancer recurrence. Caring for adult survivors of JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 27 NUMBER 15 MAY 2